Posttraumatic Hematuria With Pseudorenal Failure: A Diagnostic Lead For Diagnosing Intraperitoneal Bladder Rupture.

Hindawi Publishing Corporation
Case Reports in Emergency Medicine

Volume 2016, Article ID 4521827, 3 pages
http://dx.doi.org/10.1155/2016/4521827
Case Report
Posttraumatic Haematuria with Pseudorenal Failure:
A Diagnostic Lead for Intraperitoneal Bladder Rupture
Ketan Vagholkar and Suvarna Vagholkar
Department of Surgery, D.Y. Patil University, School of Medicine, Navi Mumbai 400706, India
Correspondence should be addressed to Ketan Vagholkar; kvagholkar@yahoo.com
Received 15 May 2016; Accepted 11 July 2016
Academic Editor: Chih Cheng Lai
Copyright 2016 K. Vagholkar and S. Vagholkar. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Bladder rupture is a very morbid injury following blunt or penetrating lower abdominal trauma. Prompt diagnosis is crucial to
initiate optimal treatment. Intraperitoneal bladder rupture is associated with haematuria and biochemical features of renal failure.
Cystogram is diagnostic. Immediate open surgical repair is the main stay of treatment. A case of intraperitoneal rupture diagnosed
preoperatively by the presence of haematuria and pseudorenal failure is presented to highlight the association of posttraumatic
haematuria and pseudorenal failure in such injuries.
1. Introduction
Intraperitoneal bladder rupture is a morbid injury associated
with both blunt and penetrating trauma. Penetrating injury
makes the diagnosis of bladder rupture much easier. However
blunt injury with no associated pelvic fracture makes diagnosis of intraperitoneal rupture very difficult. The haematological changes of acute renal failure in such patients usually
mislead the attending surgeon in arriving at diagnosis [1].
A case of intraperitoneal bladder rupture following blunt
abdominal injury accompanied with features of acute renal
failure best described as acute pseudorenal failure and haematuria is presented with a view to highlight this association.
2. Case Report
A 27-year-old male patient was admitted to our surgical
facility with history of a fall from a bus while being under
influence of alcohol.
The patient was taken to nearest hospital from where he
was referred to our surgical unit two days after the injury.
On admission patient was fully conscious and gave
history of an alcohol binge following which he had a fall from
a moving bus. He had severe haematuria on admission. There
were no external marks of any other injury. Patient had no
other comorbid medical conditions.
On examination patient had a pulse of 96 beats/min,

blood pressure was 120/70 mm of Hg, and he had pallor.
Perabdominal examination did not reveal any distension,
tenderness, rebound tenderness, guarding, or rigidity. There
was no external evidence of any injury in the thoracoabdominal region. The genitalia were normal.
Patient passed urine which showed gross haematuria. As
patient had passed urine by himself with no surrounding
soft tissue swelling a trial of catheterisation was given. The
catheter could be passed in smoothly without any resistance.
Approximately 500 cc of frank haematuric urine was drained.
Blood investigations revealed a haemoglobin of 16.5 gm
with haematocrit of 40. Total count was 6500, blood urea
nitrogen was 45 mgm%, serum creatinine was 7.4 mg%, and
serum electrolytes were within normal range. Intravenous
resuscitation was given with normal saline causing clearing of
haematuria with decrease in the tachycardia. Patient underwent plain CT scan of abdomen which revealed normal upper
abdominal viscera. However the pelvis revealed a suspicious
breach in the posterior wall of the urinary bladder (Figure 1).
Plain cystogram obtained by instilling 300 cc of diluted
contrast revealed gross leaking of contrast into the general
peritoneal cavity (Figure 2). A repeat serum creatinine was
done at this stage and showed significant fall and was reduced
to 2.5 mg%. Patient underwent exploratory laparotomy. At
laparotomy methylene blue was instilled into bladder through

the per urethral catheter. A large rent in the posterior wall
of bladder measuring 3 cm horizontally and 1 cm vertically
was identified (Figure 3). The rent was sutured in two layers
by absorbable suture material with adequate drainage of
bladder by both suprapubic and per urethral catheter as well.
Postoperative recovery was uneventful. Postoperative serum
creatinine was 0.8 mg%.
state of the bladder it may rupture intraperitoneally or extraperitoneally. The urinary bladder assumes a variable position
in the abdominal cavity depending upon volume of its content. When it is empty it lies deeply in pelvis, when full
becomes intraperitoneal organ.
Trauma to the lower abdominal wall while the bladder is
fully distended can cause damage ranging from a contusion
to frank rupture. If there is no associated injury such as
pelvic fracture the abdominal signs may be subtle. This can be
misleading resulting in failure to clinically diagnose a serious
bladder injury. However severe haematuria should raise a
strong suspicion of a bladder rupture.
Urinary extravasation into the free intraperitoneal cavity
in large volume can lead to diffusion of solutes and toxins
excreted in urine along the concentration gradient, a phenomenon described as reverse autodialysis [1, 2]. The more
the delay in presentation and diagnosis, the more severe the
biochemical abnormalities [3].
This was typically seen in the case presented where serum
creatinine on admission was high and showed a steady
decline to normalcy after drainage and repair. Therefore in
a case of posttraumatic haematuria one needs to be aware
of the fact that features of acute renal failure are seen. The
serum creatinine levels are usually very high. However the
other renal parameters are surprisingly normal despite a very
high creatinine. This phenomenon is best described as acute
pseudorenal failure [4]. A combination of haematuria with
features of acute pseudorenal failure should therefore raise a
strong suspicion of intraperitoneal bladder rupture.
The diagnostic imaging modality is plain cystogram,
which typically reveals the extravasation of the contrast into
the general peritoneal cavity as was seen in the case presented
(Figure 2). CECT can also be done. It will not only reveal the
bladder rupture but also reveal the status of the bony pelvis
and other abdominal viscera including vascular injuries.
Ultrasound evaluation will reveal free fluid in the peritoneal
cavity. An ultrasound guided aspiration of fluid will help in
confirming the diagnosis as well as determining the choice of
antibiotics based on culture studies of the urine aspirate.
However a plain cystogram is superior to a CT cystogram
or an ultrasound [5]. This has been revealed in various studies. However CECT is indicated in most cases of both blunt
and penetrating abdominal trauma to rule out concomitant
visceral injury which could otherwise be missed [57].
Surgery is the main stay of treatment in intraperitoneal
bladder rupture [8, 9]. Identification of the rent with a twolayered closure by absorbable suture material followed by
adequate drainage of bladder is best standard of care. In rare
cases of smaller leaks seen in patients with severe comorbidities such as diabetes or COPD a trial of conservative
treatment can be contemplated.
3. Discussion
4. Conclusion
Diagnosis of rupture of the urinary bladder is a challenging

issue. The etiology may vary from trauma either blunt or
penetrating to spontaneous rupture. Depending upon the
Frank haematuria following blunt abdominal injury associated with biochemical features of renal failure should strongly
raise the suspicion of intraperitoneal bladder rupture.
Figure 1: Plain CT scan showing the rent in the bladder marked by

the arrow.
Figure 2: Cystogram showing extravasation of the contrast into the

peritoneal cavity marked by arrows.
Figure 3: Intraoperative confirmation of the rent in the posterior

wall marked by black arrows after instilling methylene blue per
urethral.

A plain cystogram plate is both diagnostic and confirmatory.
Prompt surgical exploration with repair and bladder
drainage is the mainstay of treatment.
Competing Interests
The authors declare that there are no competing interests
regarding the publication of this paper.
Acknowledgments
The authors would like to thank the Dean of D.Y. Patil University, School of Medicine, Navi Mumbai, India, for allowing
them to publish this case report. The authors would also like
to thank Parth K. Vagholkar for his help in typesetting the
paper.
References
[1] A. Dees, S. A. Kluchert, and A. C. M. Van Vliet, Pseudo-renal
failure associated with internal leakage of urine, Netherlands
Journal of Medicine, vol. 37, no. 5, pp. 197201, 1990.
[2] S.-C. Chen, J.-M. Chang, C.-S. Wang, C.-H. Kuo, and H.C. Chen, Intraperitoneal bladder rupture presenting as acute
bloody ascites and oliguric acute renal failure in an alcoholic
liver cirrhosis patient, Clinical Nephrology, vol. 72, no. 5, pp.
394396, 2009.
[3] S. K. Kilari, L. Y. Amancharla, V. L. D. Bodagala, A. J. Mulakala,
J. V. Bushan, and S. K. Vishnubhotla, Pseudo-renal failure due
to intraperitoneal bladder rupture and silent subdural hematoma following a fall in an alcoholic, International Urology and
Nephrology, vol. 39, no. 3, pp. 947949, 2007.
[4] C. F. Heyns and P. D. Rimington, Intraperitoneal rupture of the
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[5] A. F. Morey, A. J. Iverson, A. Swan et al., Bladder rupture after
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[6] S. L. Mee, J. W. McAninch, and M. P. Federle, Computerized
tomography in bladder rupture: diagnostic limitations, Journal
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[7] C. A. Haas, S. L. Brown, and J. P. Spirnak, Limitations of routine
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[8] A. J. Deck, S. Shaves, L. Talner, and J. R. Porter, Computerized
tomography cystography for the diagnosis of traumatic bladder
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Hindawi Publishing Corporation

Case Reports in Emergency Medicine

On examination patient had a pulse of 96 beats/min,

Case Reports in Emergency Medicine

laparotomy methylene blue was instilled into bladder through

Diagnosis of rupture of the urinary bladder is a challenging

Figure 1: Plain CT scan showing the rent in the bladder marked by

Figure 2: Cystogram showing extravasation of the contrast into the

Figure 3: Intraoperative confirmation of the rent in the posterior

Case Reports in Emergency Medicine

Hindawi Publishing Corporation

Hindawi Publishing Corporation

Hindawi Publishing Corporation

Hindawi Publishing Corporation

Submit your manuscripts at

Hindawi Publishing Corporation

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Research and Treatment

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Oxidative Medicine and

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